Patient Inquiry Form

First Name

Last Name

Age

Date of Birth

Gender

MaleFemale

Height (cm)

Weight (kg)

Passport Number

Email

Phone

Address

Name

Email

Phone

Address

Relationship to Patient

Planned Date of Surgery

Date of Arrival in Bangkok

What procedures do you require?

What results do you expect?
(Please be as specific as possible)

Questions to Surgeon

Diabetes or blood sugar problem:

YesNo

Thyroid problems

YesNo

Heart problems

YesNo

Lung problems

YesNo

Blood pressure problems

YesNo

Kidney or Liver problems

YesNo

Blood disorders

YesNo

Previous/current history of cancer

YesNo

Do you have any medical
conditions not mentioned above?

Do you have any allergies to food, drugs, etc?

Do you smoke?

YesNo

If yes, how much do you smoke?
When did you last smoke?

Do you drink alcohol?

YesNo

If yes, how much do you drink?

List all medications you currently
take including dosage for each

Have you ever taken an anticoagulant such as
Coumadin, Heparin, or a daily Aspirin?

YesNo

If yes, when was your last dose?

Do you take birth control pills, hormone replacement
medication, or wear a hormone patch?

YesNo

Are you pregnant now?

YesNo

Are you planning any more pregnancies?

YesNo

When did you last deliver a baby?
(Month & Year)

When did you last breastfeed?
(Month & Year)